Joyce, Sarah NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
s Name First Middle Last Sex
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Date of Death Age If Veteran of 11.S.Armed Forces,.............................................
9
War or Dates
Place of Death— Hospital, Institution gr
City,Town o illage , ' Street Address fAM
!" Cause of Death j ...................... .... 1 v .. .
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< Med'ical Certrfier,:...:,:.::Na�e..........s.................
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Address
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Death Certificat ed District Number : Register Number
City,Town or illage n V
Date metery or 9femato
ry
❑Burial
v
9.90 ......:::::::::::. :1
Cremation Address
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Z> / Place Removed
Date
8 ❑ Removal and/or Held
and/or Hold ...........:::::::::::::::::::::::>::::.::::.:::::::::.............:::::::::::::::::::::::::::::.:::::::::::::::::......::::::.......... ::::......:............::::::::::.....:
Address
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ra ; Date [ Point of
N []Transportation by Shipment
01 Common Carrier .....................................................................................................................................................................................................
................................................
Destination
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❑ Disinterment Date Cemetery Address
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❑ Reinterment etery A d Address
Permit Issued to Registration Number
Re ton
9
Name of Funeral Firm
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Name of 9 Disposition or to Whom Funeral Firm Makin Dis o
Remains are Shipped, If Other than Above Address
Permission Is here y granted to dispose of the huma remains describe a ove as Indicated.
Date Issued Registrar of Vital Statistics
r� (sign re)
District Number 5/ u Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit
on:
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Z' Date of Disposition " ! Place of Disposition 110,/ ,4//, J ell R0/�/a J
(address)
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(section) (lot number) (grave number)
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p; Name of Sexton r Person in arge of Premi es
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(please print)
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Signature Title
DOH-1555(9/86)p 1 of 2(formerly VS-61)